RELACIÓN ENTRE FRAMEWORKS Y BUENAS PRÁCTICAS

Methadone maintenance as a treatment for heroin addiction.

There is an apparent paradox in the treatment of heroin users whereby many NHS treatment services offer compulsory abstinence based programmes. This paradox arises because of splitting in the medical and allied social science professions as to the whether heroin addiction is a chronic relapsing condition that addicts will battle with for the rest of their lives or an “illness” that can be treated and eradicated. What makes people come forward for treatment is the subsequent consequences that arise because of the drug use. These disadvantages may, at the beginning of drug use, seem to be advantages. For example, time is employed by most heroin users in a continual search for money and drug supply, this leads to associated criminal activity.

loss of relationships and breakdown of physical health. Initially the activity provides a structure to the day and an escape from day to day activities.

Some users may be in treatment as they have no other choice as the courts have made an instruction for compulsory treatment. One of the main obstacles facing drug services is the high relapse rates in drug users once treatment has ended. It may be that services are providing something more than just methadone, a structure or focus for drug users.

An American study found that it is not the patient characteristics that vary with regard to treatment effectiveness but the service provision (Kreek 1983). More effective treatments have high patient attendance rates and a close, consistent and enduring relationship between staff and patient. Conversely the less effective treatment programs are characterised by poor patient attendance, inadequate methadone medication and high rates of staff turnover.

It must be remembered when talking about service provision that patient

characteristics and presenting problems continually change. For example, disease entities have altered with the problems due to hepatitis and HIV and their associated psychosocial sequalae. Additionally there have been changes in drug availability and fluctuations in type of drug popularity. The 1990’s have seen an increase in the popularity of stimulant drugs such as MDMA (ecstasy). Social structures also change as employment and housing availability varies. The problem with treatment

component of addiction alone is that the approach ignores the social network surrounding drug use, in addition to the potential aetiology of drug use.

Treatment centres seem to be divided by high and low dose criteria for methadone prescribing. This is conceptualised as being analogous to overindulgent parents supplying too much vs. the careful, overprotective parent not giving enough. There is a need for the philosophy of methadone prescribing to take on board the concept of an adequate methadone dose and this point will be expanded upon below. Overall the aim should be for methadone maintenance to be available for as long as is desired by the patient and as long as continuing benefit is derived from treatment.

There is a large amount of literature on the philosophy of treatment approaches relating to abstinence or maintenance prescribing practices. One of the main questions is the extent that this philosophy effects patients retention in treatment. If methadone is considered to be the treatment of choice for heroin addiction then it is essential that treatment is maintained. For example, the reported health benefits from methadone treatment include reduced injecting and the subsequent reduction in HIV and

Hepatitis risk. Caplehom (1996) reported that physicians’ commitment to abstinence- orientated policies was highly correlated with patients’ premature discharge. In another study, Caplehom (1994) also found that abstinence orientated treatment centres are also less able to attract heroin users into treatment.

The efficacy of methadone maintenance treatment can only be established by thorough outcome studies. A recent American report is asking for more outcome studies to be

performed on all aspects of methadone maintenance. The nature of the American health care system means that it is more market driven than the British NHS and therefore insurance companies that have to pay large sums for methadone treatments and are questioning the evidence as to its value. They are looking in the future toward more integrated physical health care at methadone treatment units and vocational training and job placements are seen as critical treatment components and outcome measures to monitor treatment success. Further work is also needed that looks at the intergenerational drug use by implementing parenting skill groups and family therapy throughout treatment settings.

The question of how to measure treatment success is a complex one. Is success defined as: decreased illicit drug use; improved physical and emotional health; decreased anti-social activities or improved social functioning ? Most people would say that it is a combination of all of the above, but that there needs to be a change in the practice of outcome measurement from performance measures to process orientated reviews. Process orientated reviews focus on the method that outcome variables are achieved. The main problem is that there is no agreement as to what constitutes successful outcome and before outcome can be measured treatment objectives need to be clarified.

Despite poly-drug use the aim of methadone treatment is to achieve a sufficient methadone dose to stabilise the patient and retain the patient in treatment as longer treatment episodes are correlated with increased success (Hubbard et al, 1989). It

must be remembered that there are few compelling reasons to discharge a patient from treatment in the light of the risk of HIV and other health related complications.

Methadone maintenance doses.

There still seems to be confusion and inadequate knowledge about methadone dosage. As early as 1966, Dole stated that; “At present, the most that can be said is that there seems to be a specific neurological basis for the compulsive use of heroin by addicts and that methadone taken in optimal doses can correct the disorder. The proper methadone dose is one that prevents ongoing heroin use. Many methadone treatment units persist in using sub-therapeutic maintenance doses”. Research studies have shown that the higher the methadone dose the lower the elicit heroin use (Ball and Ross, 1991). An additional facet of methadone dose is its effect on treatment

retention. Capelhom and Bell (1991) found that the level of dose was the single most important factor in retention in treatment programmes.

Wolff et al (1991) found a linear relationship between methadone dose and methadone concentrations in the plasma, i.e. a optimum blood level and optimum dose effect. The mean plasma levels of methadone at the 80mg dose are very close to the 400ng/ml suggested as ideal for treatment effectiveness. Their study reconunends a dose calculated on an individual basis following the stage approach in Table 29.

Table 29: Recommended dose ranges over the course of treatment (determined on an individual basis).

phase purpose range

initial dose relieve abstinence

symptoms

20 - 40 mg

early induction reach tolerance threshold

+/- 5-10 mg (3-24 hours)

late induction establish adequate dose (desired effects)

+/- 5-10 mg ( 5-10 days)

maintenance maintain desired effects usually 80 +/- 20 mg (may be more than 100 mg or less than 50 mg)

One of the main obstacles to clinicians adequately prescribing methadone is their fear of overdose if patients continue to use other drugs. Another fear is that there will be an increase in the selling of methadone to secure heroin. There is also a risk to children of methadone users as it is potentially lethal to children if taken by mistake.

This research validates other research projects in that one of the potential explanations for the high amount of other drug use is the insufficient methadone dose that

participants were being supplied. This may also account for their increased craving for heroin once given an additional dose.

Poly-drug abuse.

One of the main problems is that there is a high frequency of opioid dependence and conjoint other drug use. One of the main causes of death amongst drug users is the combination of alcohol, prescribed methadone and other illicit drug use. Stimulant use is high amongst heroin users and can be expected to persist independently of

methadone prescribing as methadone does not treat stimulant dependence and stimulants have a different pharmacological action. Research has found that cocaine use and methadone use together is especially high (Kosten et al, 1990) and that when a reduction or abstinence from heroin use occurs the risk of increased cocaine use is high. Patients turn to cocaine use as heroin stops giving a euphoric effect if

methadone is taken in a large enough dose. Another possibility is that cocaine is a CNS stimulant and that methadone users are self-medicating to counter-balance the sedative effects of methadone. One further explanation that is less supported by research is the proposal that heroin users as with all drug users have “addictive personality” profiles and the absence of the use of one drug such as heroin results in the increase use of an alternative drug or the beginnings of use of a new drug.

It must be remembered that it is possible that drug using patterns vary according to where the research is conducted. It is possible that different cities and populations favour different types of drugs. This is one of the potential explanations why research studies vary greatly on the reporting of additional drug use. Dupont and Saylor (1989) found 51% of their sample had urine samples that contained evidence of cannabis.

Another possibility is that methadone users will engage in an activity known as “boosting”. This is when other drugs such as antihistamines or barbiturates are taken to enhance the methadone’s opioid effect. However, the most substantial effect is to achieve a stronger than usual primary effect from the second drug, for example antihistamine or barbiturate sedation. The greatest risk in this practice is accidental overdose. It is also thought that opiate users use benzodiazepines to reduce the anxiety that often occurs as a result of the opiate levels in their blood dropping when withdrawing.

In an inner city area such as where this research was conducted it could be speculated that additional drug use is for none of the above reasons. It is possible that the sample are poorly motivated and that their enrolment in methadone treatment is as a way of ensuring a supply of methadone should money or drug supply problems occur. Additionally the associated high forensic activity means that some users are forced into treatment to avoid custodial sentencing or that they need to be seen to be addressing their drug use to receive social security benefits and to keep custody of their children. In clinical terms such feelings are attributed to the pre-contemplation or contemplation stage of motivation (Prochaska and DiClemente, 1992). This means that the participant actually wants to continue heroin use but methadone is the legal alternative and the user has not yet decided on whether the adverse consequences of their heroin use means that they want to give up. It must also be remembered that drug use is difficult to give up without awareness of the role that it fulfils in the individuals life. For some it is an escape from trauma and/or the reality of everyday existence or just a normalised part of daily life.

Urinalysis

One of the main methods of monitoring the dmg use of patients enrolled in

methadone maintenance treatments is by urine testing. In the USA, urine screening has been a required procedure in methadone maintenance treatment before insurance companies will pay for treatment. However, in Britain there is little guidance to the use of the monitoring procedure. In general the policy seems to be that it should not be used solely as a determinant of treatment i.e. to force a patient out of treatment, but rather as a guide to modify treatment approaches.

There are variations on ensuring that the procedure involved is maximised to ensure an accurate result. One way is to ensure that the patient does not take a sample in with them or that they don’t get someone else to do their sample for them. In many services the toilets have cameras in to monitor patients. It must however be

considered within the context of the human rights of the patient to dignity and respect. It must also be noted that the there are incidences when the urine screening test procedures have produced false positive and negative results (Morgan, 1984).

It has been suggested that the most efficient procedure for the collection of urine samples is random samples and that patients should be informed at the initial stages of treatment of the clinics policy. Minimising the falsification of urine results and client- staff relationships are best fostered if the patient does not see the procedure as a way

of punishing them or detrimentally affecting their treatment. The ideal use of the results is within clinical counselling situations as a basis for discussion.

Urine testing also needs to be analysed with the knowledge that different drugs are metabolised in different ways and therefore show in the urine for different amounts of time. For example, cannabis can stay in the urine for up to 28 days, a long time after there would be any likely clinical effects.

The disparity in clients reporting of illicit drug use compared to urine toxicology is likely to be as a result of fear of detection and punishment, (for example, take-out prescription privileges being withdrawn). The implications for the staff-client relationship due to other illicit drug use determined by urine results is discussed below.

The implications for psychological therapies.

The boundaries between counselling and other psychological approaches in the treatment of drug users appears to be particularly vague. In general counselling is considered the approach that generic mental health workers use to manage the overall case, i.e. to identify and address specific problems in the area of drug use, physical health, interpersonal relationships, family interactions, vocational or educational goals. Additionally they act as a liaison role between psychiatrists, medical institutions, courts and social services. Their aim is broadly as case manager as described above, to help the patient develop coping strategies for current problems and to attend to the

running of the treatment programs, its rules, privileges and policies. Treatment should therefore be geared toward both short and long term goals.

There is a boundary between this generic drug counselling and psychotherapy that is often ambiguous. In general psychotherapeutic approaches can be used in the same way as general psychotherapy although there is often the opinion voiced that lengthy psychotherapy cannot be performed whilst the mind altering drugs are being taken. More specific psychotherapeutic methods used to treat drug users include relapse prevention and motivational interviewing techniques. These treatments embody general cognitive behavioural principles, i.e. focusing on uncovering and understanding the relationship between automatic thoughts and underlying

assumptions on problematic feelings and behaviours. These approaches tend to relate the above to the specifics of the drug using behaviour of the individual.

The research finding in this study that drug users are less suggestible than the general population may have implications for the efficacy of these psychological treatments. Cognitive restructuring techniques may be difficult to apply although treatments validated with drug users may have included this concept in their design. It is also possible that less suggestible clients may require longer in psychotherapeutic

treatments than clients that are more suggestible. Additionally less suggestible people may be resistant to change and their lack of response to negative feedback could also contribute to their resistance to change their drug using behaviour. This lack of suggestibility could be analogous to the psychoanalytical concept of ‘resistance’.

The policy regarding urine testing in relation to the overall treatment philosophy is also an important facet of the client-therapist relationship. For example the treatment overall philosophy may be one of abstinence and therefore urine screening is used to monitor other drug use and as a tool for changing treatment if other illicit drug use is detected. Such policies can foster an atmosphere of non-disclosure to other drug use and craving which makes therapeutic interventions limited in their usefulness to deal with the clients current issues and situation. In this research 27.78% of participants had positive urine tests to heroin when they had reported no use. This is within a research setting where disclosure has no treatment implications. Although participants were told this before the research began, they may have doubted it as the researcher was also clinical staff at the service. It is also interesting that key-workers are obviously not aware of the extent of their clients additional drug use as they chose clients whom they thought were more stable and therefore that illicit use would be minimised.

Especially within psychoanalytic literature, there is a lot of references to the honesty of the client within a therapeutic relationship. Part of the therapeutic process that appears not to be present in the key-working role is the negotiation of goals that the client also agrees to. Current practices regarding treatment goals seem to be dictated by treatment philosophy and it is therefore unsurprising that relapse is high and the unreported use of illicit drugs is common. Research supports the view of the importance of the relationship between staff and patients in treatment outcome, although none has been done that isolates the specifics of the relationship and their effects (Kreek 1983). However, it is unlikely that a good therapeutic relationship can

be fostered if the patient cannot be honest about their drug use as it is against the services treatment philosophy.

Craving is an important part of cognitive-behavioural interventions such as relapse prevention (Marlatt and Gordon, 1978). It is assumed that craving heroin leads to heroin use and relapse. It is not possible to attribute craving to a purely biological or psychological effect, it is likely that it is an interaction between the two. Craving is the same as many aspects of addiction treatment in that there is often a separation

between the behavioural and medical consequences and therefore the subsequent treatment adopted varies according to what the craving is attributed to originating from.

For example, a dealer may move in next door to a patient and they find that their cravings increase. Therapeutic efforts would need to focus on resolving the situation